BETHESDA, MD—“Combat injury is not an event. It’s a process.” Those words, spoken by Stephen Cozza, MD, associate director of the USUHS Center for the Study of Traumatic Stress, could have been taken as the central theme of DCoE’s Trauma Spectrum Conference held last month on the campus of NIH. The conference has focused attention for the last three years on the effects of combat trauma not only on the soldier, but also on their spouses, children, friends, and society as a whole.

Speaking on the topic of servicemember reintegration, Cozza said that, while it is accepted that most combat trauma—both physical and mental—will take years to recover from, there is little known about the best ways to go about that recovery, and how the process will eventually affect a servicemember’s family and life.

“There are alternating periods of medical stability, instability, community relocation. Very often servicemembers are returning to hospitals for surgical procedures,” Cozza said. “It’s a continual engagement with the medical system, sometimes with very complex decisions needing to be made, not always at the [time of the] injury.”

That engagement and the periods in between are experienced by the family, as well as the patient. Spouses quit their jobs; children are left with relatives or spend weeks in frightening hospital settings; routines are shattered; and stress begins to weigh on everyone in the family.

The Cascade of the Event

It is important that physicians and counselors think, not just about the treatment of an injury, but about the events surrounding that treatment, Cozza said. A misstep in communication with a family, or in their interaction with the hospital, can exacerbate things, both for the family and the patient.

The first step in that cascade is notification that a family member has been injured in combat. Sometimes that occurs formally, but with the increased use of the Internet and satellite phones, family members frequently know about an injury within hours after it occurred. However, that information is sometimes incomplete or inaccurate.

Then there is the question of how to communicate it to any younger children in the family. There is an instinct, Cozza said, to protect the child. “Kids witness initial distress that they may be confused about. There is this initial feeling that kids can be protected from information, which I think we all realize is a mistake. Kids may not need all the information, but they need enough of it so they recognize and understand what’s happening.”

There are the travel and the family separations. Soldiers are housed in hospitals across the country, necessitating spouses to go long distances to see them. Younger children may come with the parents, while older ones are left to stay with relatives.

Following that is the period of inpatient treatment. “The hospitalization can take years and hospitals can become places where children and families spend a lot of time,” Cozza said. “This is a period of time where there’s a lot of stress on the families. Existing tensions worsen. It can lead to an undermining of family function.”

This is also a time when caregivers need to begin thinking about how treatment intersects with the family. “Hospitals that are caring for injured parents need to be places where children are welcome,” Cozza said. “We also need to find ways to help parents create developmentally appropriate language for kids to communicate [about an injury].”

After hospitalization there are the long-term family challenges: transitioning from military careers; moving to new neighborhoods; adapting to new schools, new peer groups, and new activities. Throughout all of this, there will be the constant returns to the hospital, the outpatient rehabilitation, the need for the veteran to relearn how to live, and the need for the family to relearn how to communicate and relate.

Impact of the Injury

Rehabilitation is not just physical, Cozza said. “It’s not just [learning] how to throw a ball again, but how do I throw a ball to my daughter again. How do I reengage that relationship?”

Both the injured parent and the child might have to drastically reevaluate the parent-child relationship. For the veteran, usually a young man or woman whose body has been changed dramatically, they may no longer fit their own concept of an ideal parent.

Children may not always understand what the injured parent is experiencing, especially if communication is poor. For young children especially, seeing an injured parent can be traumatizing and may spark their first grappling with the concept of mortality. But children may not verbalize those thoughts.

“Children can be quiet about it or express their distress in a way that’s nonverbal,” Cozza said. “And with invisible injuries, parents can be irritable or reactive and children don’t know how to understand or react to it.”

What begins as a chronic injury in the veteran can eventually lead to chronic problems with their children. “There’s a lot of literature out there showing that the presence of parental PTSD has a [trans]generational impact and can be profoundly challenging for families,” Cozza said. “Looking at Vietnam veterans with PTSD— their families suffer diffuse and severe problems in marital and family adjustment, broad relationship problems, and often dissatisfaction with parenting relationships.”

PTSD can be especially problematic with family functioning, since many of the symptoms that define post-traumatic stress directly impact relationships: emotional numbing, avoidance, and comorbid depression, among others. Veterans with depression or PTSD are shown to have increased problems in the area of family functioning and in interpersonal relationships. They also have challenges in the area of perceived parenting capacity.

Many of these symptoms do not appear until the servicemember is out of the hospital. According to Cozza, 70% of OEF/OIF veterans who had a PTSD diagnosis seven months after returning home were not diagnosed at the time of initial injury. “Most families were at least a year past the initial injury when the symptoms of PTSD and TBI began to strongly present themselves.”

Future Research</p>

“What are the multiple variables that could contribute to family stress, how do they contribute; and how can we understand how to better develop programs of prevention that identify those that are at greater risk?” Cozza asked. “We specifically need to target families at risk so we know who and when and at what times families would best benefit from support.”

To do that, much more needs to be understood about how the effects of combat trauma are felt by families. A clinical record review conducted earlier this year of the impact of injuries on families used semi-structured interviews with spouses of extremely injured servicemembers one to three months after hospitalization.

The spouses reported widespread impact of the injury on their lives, and researchers noted that those families with high pre-injury or pre-deployment family stress were significantly more likely to report problems post-injury.

In a separate study, families were asked what their needs and concerns were. Major themes included a desire for better quality service in delivery of care, as well as need for family-centered care. “Families also expressed a desire to stay connected to a sense of family strengths,” Cozza said. “They had strengths that they brought to this and [they wanted to] use those strengths to address the injury.”

Studies are currently underway to identify what those strengths might be and how they could help prevent family stress. The Center for the Study of Traumatic Stress is examining the intervention of the Families Overcoming Under Stress (FOCUS) framework, a resiliency-building intervention for families facing the challenges of multiple deployments and parental combat-related psychological and physical problems.

“It’s not just about the injured service member,” Cozza said. “We need to be thinking about how we take care of that entire family through the injury recovery.”